'Tis the season of miracles. A year that began with lumps of coal for the healthcare industry ends with Christmas presents wrapped in ribbons of cautious optimism.
The Affordable Care Act still stands. Medicaid has not been undermined. And the drive to improve quality and lower costs—a cornerstone of healthcare policy for the past decade—remains largely intact.
The surprising victory by Democrat Doug Jones in Alabama's Senate race creates an all-but-insurmountable barrier for Republicans still seeking to dismantle the insurance and Medicaid expansions contained in the ACA. And while the tax legislation still repeals the individual mandate, Republican Sen. Susan Collins of Maine has conditioned her vote on renewing the cost-sharing subsidies that make ACA-compliant plans affordable for millions of low-income individuals.
Other moderate Republicans are beginning to make their voices heard. Rep. Greg Walden of Oregon insisted last week that Congress include reauthorization of the Children's Health Insurance Program in the stop-gap government funding bill that must pass before year-end.
But avoiding worst-case scenarios is no reason to break out the Champagne as we make the turn into the new year. While the final tallies from this year's truncated open-enrollment season are not yet known, the likely outcome is several million fewer people signing up for plans. For the first time in our history, the drive to provide universal coverage for all Americans will have suffered a deliberate, policy-driven setback.
Declining enrollment will create individual insurance markets in many states that are smaller and sicker than 2017. This will set the stage for another round of double-digit premium increases next year, and provide grist for the mills of politicians still intent on "repealing and replacing" the ACA.
It will also spill over into larger-than-expected increases in the employer-provided insurance market. Rising uninsured rates inevitably lead to higher uncompensated-care costs among the nation's providers, which eventually get passed along to the fully insured.
However, there will be a countervailing force as America heads toward the midterm plebiscite on the presidency of Donald Trump. Alabama's election results have dramatically shifted the debate over healthcare coverage to the left.
It comes on the heels of a major shift in public opinion that took place during this year's assault on the ACA. The top line of the latest Kaiser Family Foundation tracking poll, released in mid-November, revealed a public marginally supportive of the law—50% in favor compared with 46% opposed.
But that reverses the nation's mood from a year ago, when a plurality opposed the law. And percolating below the surface is a surprising surge in public support for greater government involvement in the provision of healthcare.
When asked last month if adults at any age should be allowed to pay a premium to join Medicare, fully 72%, including a majority of Republicans, said yes. When the question was limited to allowing buy-in for people between 50 and 64, the number approving rose to 77%.
Even when cautioned that this public option would give government more control over healthcare and reduce payments to providers, 58% still supported this movement toward "Medicare for all." And when offered the positive spin that it would be more affordable than ACA plans and make it easier to extend coverage to rural and hard-to-insure areas, opposition dropped to less than 20%.
Want more? Well over half the population now views terms like "Medicare for all," "universal health coverage," and "national health plan" very or somewhat favorably, compared with just a third of the population who are very or somewhat negative about those concepts. Even "single payer" garners a 48%-to-32% plurality with the rest undecided or refusing to answer.
Last week's election in Alabama—one of the most conservative states in the nation—has set the stage for a very interesting primary season for both political parties. Happy New Year!